Alveolo-dental trauma
1) Introduction : Dentoalveolar trauma involves several tissues and structures. It is necessary to know the structure of a healthy tooth and its supporting tissues to determine the consequences of trauma, establish a treatment plan and evaluate its prognosis.
Dental trauma often results in partial or total loss of dental tissue, causing serious aesthetic and functional damage to the victims.
Increasingly frequent during childhood and adolescence, they also tend to increase in adults due to the intensity of the pace of life (sports, traffic accidents, etc.) not to mention the increase in violence.
Treatment of dental trauma requires a multidisciplinary approach involving virtually all dental specialties.
2) Etiologies: At primary school age, the most important cause is falling or hitting obstacles, most often leading to coronary fractures.
During adolescence, the practice of team sports according to Andreasen is the cause of dental trauma in the subjects who practice them (elbow or punch).
Car accidents affect all age groups.
Fights and other abuse suffered by women.
In any case, protrusion of the maxillary incisors with insufficient lip closure represents a risk factor
3) Mechanisms of dental traumatic injuries; Dental trauma can result from direct or indirect trauma.
Direct trauma : Occurs when the tooth itself receives the shock, the blunt agent being for example the ground, a chair, a table, a door, etc. Direct trauma concerns the anterior teeth and particularly the maxillary incisors.
Indirect trauma : Is the result of a violent shock of the mandibular arch against the maxillary arch, for example, following a blow to the lower part of the chin. The dental injuries that result are coronal or coronoradicular fractures of the premolars and molars. This type of trauma is also the cause of condylar or symphysial bone fractures.
4) Classification of dental trauma
Alveolo-dental trauma
Extrinsic
Intrinsic
Terminology and definitions
Trauma described as intrinsic represents all alveolar and dental lesions caused by shock, with an impact on the orofacial region.
These traumatic lesions of the tooth and surrounding tissues include alveolar fractures and dislocations, as well as post-traumatic sequelae, mainly coronal and root resorptions.
Extrinsic trauma involves not only the tooth and ligament but also the alveolar and maxillary bone, as well as the soft tissues of the face, lips and oral mucosa.
5) First consultation of the trauma patient;
When the patient consults immediately after a trauma, it is necessary to assess all the damage suffered by the dental and surrounding tissues (pulp, desmodont, alveolar bone, etc.). However, it happens that the patient consults later, in which case it is necessary to take into account the impact that the time factor can have on the prognosis.
5-1: Anamnesis
The anamnesis is essential. It must specify the circumstances of the trauma, guide the clinical examination and direct the therapeutic choice.
How ?
Or ?
When ?
Question 1: How did the trauma occur?
Depending on the answer, certain areas need to be examined more closely. For example, a direct blow to the chin can cause not only a fracture of the incisor, but also have repercussions on the cusp area and at the level of the ATM.
Question 2: Where did the shock occur?
The response allows the risks of contamination to be assessed and antibiotic therapy and/or tetanus vaccination to be initiated if necessary.
Question 3: When did the trauma occur?
This question introduces the time factor. It is a decisive element that significantly influences the implementation of certain therapies.
Also determine if there was a period of unconsciousness? Headaches? Vomiting? Visual disturbances? If so, these symptoms may indicate head trauma, and the patient should then be referred to a specialized hospital service.
The age of the patient is essential, the prognosis of certain therapies, particularly bioconservative ones, may be more or less reserved depending on this parameter.
5-2: Clinical examination
The overall assessment of the patient allows the existence of shocks or brain trauma to be detected. During an emergency consultation, the pupillary reflex, blood pressure, pulse, and the existence of epistaxis must be checked.
5-2-1: Exo-oral examination
Wounds on the face, lips and chin are inspected to determine whether or not stitches are required.
Palpation of the bony edges (nose, suborbital mass, symphysis, mandibular angle, etc.) suggests the possibility of bone fractures in the event of pain.
A limitation or deviation of the path of oral closure may indicate a condylar fracture or meniscal displacement.
5-2-2: Endo-oral examination
a) Soft tissue examination
The type and extent of traumatic mucosal injuries should be assessed, including the presence of frenulum laceration or hematomas;
Careful palpation can detect the possible presence of foreign bodies (gravel or dental fragments)
b) Examination of occlusion
Abnormalities of the maximum intercuspation position can be detected and associated with tooth displacement, coronal-radicular fractures and/or bone fractures.
c) Examination of hard tissues
Direct impact coronal fractures can result in dentinal damage and possible exposure of pulp tissue.
In the case of indirect shocks, it is necessary to look for the presence or absence of coronal-radicular fractures at the level of the molar sector.
Enamel cracks are visualized by transillumination, holding the light beam perpendicular to the vestibular mucosa at the level of the attached gingiva.
Clinically, the change in color is assessed in relation to adjacent and/or contralateral teeth. A change in color observed immediately after trauma may disappear later and should not lead to a hasty decision to depulp. Conversely, the appearance during subsequent sessions of discoloration, particularly yellow or gray, indicates calcification or pulp necrosis.
Three tests must be carried out:
Mobility
Percussion
Thermal sensitivity
* Axial mobility indicates apical section of the neurovascular bundle
* Mobility in a horizontal direction indicates either an alveolar fracture (if the mobility of one tooth causes the mobility of adjacent teeth) or a root fracture
Percussion is performed in the vertical and horizontal direction using the mirror handle in adults and the finger in children. It allows sensitivity and sound to be assessed.
Tenderness to axial percussion reveals damage to the periodontal ligament and/or the pulp vascular network.
A metallic sound during horizontal percussion indicates lateral intrusion or dislocation.
A dull sound indicates subluxation or extrusion.
The assessment of thermal sensitivity is done:
Either with dichlorofluoromethane, applied to the tooth using a cotton ball
Either by means of warmed gutta-percha.
They allow to judge the state of the pulp after the trauma. These tests can be supplemented by electrical tests
d) X-ray examination
Radiographic examination is essential to detect and confirm fractures, dental malpositions, and bone fractures. Radiographs are necessary for the diagnosis of root fractures, for the demonstration of subluxations and extrusions, and the confirmation of dental intrusions and alveolar fractures.
Sometimes it is necessary to take several X-rays from different angles to refine the examination.
1) Coronal fractures without pulp exposure
1-1: The cracks
Frequent but often neglected, cracks appear as cracks in the enamel without crossing the enamel-dentin junction. There is no loss of substance. They are caused by a direct shock to the enamel.
1-1-1: Diagnosis
Highlighted by transillumination, the light ray is directed perpendicular to the axis of the tooth, on the vestibular mucosa at the level of the attached gingiva. These cracks are often associated with other trauma, in particular dislocation, which must be investigated.
Clinical signs are non-existent. The patient sometimes complains of a slight sensitivity to cold.
Treatment
The therapy consists of abstention or the application of a sealant at the level of the crack line to prevent external colorants (caffeine, theine, etc.) from causing dyschromia.
Pulp vitality monitoring should be performed monthly for 6 to 8 weeks.
Prognosis
It is excellent, this trauma does not cause serious pulp consequences.
1-2: Enamel fractures
1-2-1: Diagnosis
Enamel loss is most often located at the mesial or distal angle of the traumatized tooth.
The cold test is positive, and the percussion test is slightly painful.
Treatment
When enamel loss is minimal, treatment consists of coronoplasty of the enamel edges with a diamond bur mounted on a turbine and under constant irrigation. This procedure may be followed by a fluoridation session or a sealant.
In other cases, it is necessary to perform the reconstruction of the tooth using a light-curing composite.
Pulp vitality monitoring will be carried out one month later, then at 3 months and then every 6 months.
Prognosis
It is excellent, the risks of pulp necrosis are very minimal.
1-3: Coronal enamel-dentin fractures
1-3-1: Diagnosis
A more or less extensive loss of substance is observed. These fractures generally affect one or two teeth. They may be associated with ligament damage (subluxation or extrusion).
Proportional to the severity of the trauma, the clinical signs are manifested by:
– Dentin hyperesthesia (pain when cold, acid and sugar, etc.)
Pain when chewing
The radiographic examination makes it possible to objectify the stage of root development, the volume of the pulp and the relationships between the pulp and the fracture line.
Treatment
Emergency treatment aims to prevent secondary damage to the pulp tissue:
Either through thermal shocks
Either by microbial invasion via the exposed dentinal tubules.
Three factors condition the treatment
– The time elapsed between the trauma and the consultation
The thickness of the residual dentin between the fracture line and the pulp
The stage of root development
Protection of pulp tissue takes precedence over aesthetic restoration.
The tooth is cleaned with physiological serum and disinfected with Mercryl
A dentino-pulpal protection is carried out (Calcium hydroxide) covered with a temporary reconstruction for 4 weeks
Temporary reconstitution can be either:
A glued composite strip
A glass ionomer
A preformed crown
Definitive treatment aims to achieve the following objectives:
Seal exposed dentinal tubules tightly
Restore aesthetics and function
Do not harm pulp tissue.
The restoration will be done with bonded composite in accordance with the operating protocol.
Post-operative follow-up
The composite restoration provides excellent sealing and must be monitored annually over time.
2) Coronal fractures with pulp exposure;
These traumas result in varying degrees of pulp exposure. The treatment decision depends on:
From the stage of root evolution
About the size of the exhibition
The time elapsed between the time of the trauma and the visit to the office.
There are two possible scenarios: mature teeth or immature teeth.
Mature teeth
If the exposure is minimal and recent, direct pulp capping or partial pulpotomy may be considered. However, the prognosis is less favorable and these techniques should be considered as emergency treatment.
If the pulp exposure is more extensive and older and if root anchorage is necessary for reconstruction, conventional gutta-percha endodontic treatment is the technique of choice.
Immature teeth (See course on Pedodontics: Apexogenesis and apexification)
From an epidemiological point of view, they represent approximately 5% in permanent dentition and 2% in temporary dentition. All dental tissues are affected: enamel, dentin, cementum and most often the pulp.
They can be classified into two categories according to the involvement of the pulp tissue:
* Simple FCR: without pulp involvement (rare)
* Complicated FCR: with pulp involvement
1: Clinical diagnosis
Most often, the fracture line is oblique, going from the incisal edge of the vestibular surface to the cervical edge of the palatal or lingual surface. It is sometimes longitudinal along the long axis of the tooth or off-center mesially or distally (scissors fracture).
The clinical symptoms are not very important, in fact only chewing mobilizes the fragments, the pain is not spontaneous but functional
2: Radiological diagnosis
Its interpretation is very difficult. In fact, in the palatal area, the fragments are very close and the fracture line is perpendicular to the central ray and therefore less visible.
It is preferable to use several incidences and in particular off-centered shots using mesial and distal angles of 20° compared to the first shot centered on the tooth.
Treatment
3-1: Simple FCR
3-1-1: Superficial fracture line : The aim of treatment is to maintain the pulp vitality of the tooth and to preserve the health of the marginal periodontium. It is necessary to remove the fragment, polish the tooth, and establish perfect hygiene accompanied by the prescription of chlorhexidine mouthwashes. After one week, the tooth can be restored with light-cured composite.
3-1-2: Deeper fracture line : In this case it is possible to obtain a supragingival limit with gingivoplasty and/or osteotomy. It is necessary to obtain gingival healing and dentin repair.
The fracture line is exposed by gingivoplasty and/or osteotomy followed by polishing of the dentin surface. Dentin protection can be achieved with glass ionomer cement.
Two or three weeks later, gingival healing is achieved and the tooth is reconstructed with light-curing composite.
3-2: Complicated FCR
In such cases, it is necessary to treat the pulp problem, the periodontal problem individually and to carry out a prosthetic restoration in the best possible conditions.
Due to pulp exposure, it is often necessary to extrude the tooth after removal of the coronal fragment in order to re-establish the biological space (approximately 2mm) allowing optimal coronal restoration.
3-2-1: Removal of the coronal fragment and orthodontic traction
3-2-1-1: Endodontic phase
Classic endodontic treatment is performed
3-2-1-2: Orthodontic phase
Orthodontic traction is performed for 4 to 6 weeks. The tooth is extruded 0.5 mm more than necessary due to physiological re-ingression. After 3 months of retention, a restoration is performed.
Orthodontic traction can be done with heavy, discontinuous forces (2 to 3 weeks) or with light, continuous traction (approximately 1mm of extrusion per month).
Alveolo-dental trauma
Alveolo-dental trauma
3-2-2: Restoration of biological space
The biological space is approximately 2 mm. This includes approximately 1 mm of connective tissue attachment located coronally to the bone edge and approximately 1 mm of epithelial attachment. 2 mm of space is required to protect the dental organ from any infectious aggression from the gingival sulcus to the periodontium. Therefore, it is essential not to harm this biological space during the treatment stages. If the biological space is lost, it must be restored before reconstruction.
Follow up
Teeth will be checked at 2 months, 6 months and 1 year after the end of treatment
Prognosis; Depends on pulp, periodontal and prosthetic prognoses
Root fractures are uncommon injuries. They are mainly observed in young people between 11 and 20 years old. The most frequently affected teeth are the maxillary incisors.
Healing of root fractures is complex because the trauma involves the pulp tissue and surrounding tissues (periodontium and bone). However, endodontic treatment is not always necessary and should not be systematically considered.
3-1: Clinical diagnosis
The clinical expression of root fractures is diverse, the tooth may appear in normal position, extruded or laterally displaced. These fractures may be associated with fractures of the external alveolar table, more rarely with coronal fractures.
3-1-1: Displacement of the coronal fragment: The greater the displacement, the more delicate the reduction.
Alveolo-dental trauma
3-1-2: Mobility: The degree of mobility depends on the severity of the trauma and the location of the fracture line. Mobility is significant when the fracture line is located in the coronal third. If the fracture line is located in the apical third, the tooth has little or no mobility. In this case, the root fracture is highlighted during the radiographic examination.
3-1-3: Pulp sensitivity tests: The test can be positive or negative. However, in the latter case, it is recommended to wait 3 weeks or even a month before initiating endodontic treatment.
3-1-4: Percussion test: This test may give a metallic sound indicating in this case that the root fracture is associated with a lateral dislocation of the coronal fragment. A dull sound indicates an extrusion of the coronal fragment.
3-1-5: Coronal dyschromia: Crown dyschromia may appear. It then most frequently presents a pinkish tint due to pulp hemorrhage. This sign may be reversible and should not be considered as a systematic indication for immediate root canal treatment.
3-2: Radiographic examination
It is essential and can reveal a clinically unsuspected fracture of the apical third. It requires several images (1 occlusal supplemented by several retroalveolar images under several incidences).
The fracture line is only radiovisible if the beam is directed between 15° and 20° relative to the fracture line.
Alveolo-dental trauma
Alveolo-dental trauma
Treatment
The two essential factors are the degree of maturation of the apex and the more or less coronal situation of the fracture line.
3-3-1: Fracture line at the apical third: This is the most favorable situation because in the majority of cases, neither mobility nor displacement of the fragments is observed. Abstention and surveillance are the rule.
However, in rare cases, there may be fracture of the external bone table. In this case the apical fragment must be surgically removed. For the coronal fragment, a retro obturation with MTA followed by a canal obturation with gutta-percha is the currently recommended therapeutic solution.
Alveolo-dental trauma
3-3-2: Fracture line in the middle third:
Treatment consists of reducing the fracture, realigning the two fragments and applying a retainer. The shorter the time between the time of the trauma and the consultation, the easier it is to reduce the fracture, since the clot is located in the space and does not interfere with the maneuver.
Alveolo-dental trauma
Local anesthesia is necessary, as the force exerted for repositioning is often significant. The reduction is assessed radiographically before performing the retention. An orthodontic wire is bonded to the vestibular surface of the teeth using composite, and adjusted to the shape of the arch; this retention is left in place for 3 months
Alveolo-dental trauma
3-3-3: Fracture line at the coronal third:
If the fracture line is supra-alveolar, the coronal fragment is removed, the apical fragment can be extruded orthodontically depending on its length. A prosthesis is then made after endodontic treatment. If the prognosis is unfavorable, the implant alternative is then considered.
Follow up
The patient is reviewed for reassessment 3 weeks, 6 weeks, 3 months after the trauma. Follow-up visits reassess the gingival crimping, mobility, percussion, pulp sensitivity tests, crown color. Radiographic examination may highlight possible root resorptions or calcific pulp degeneration.
Prognosis
There are four types of biological responses in the presence of a root fracture according to Andreasen:
Healing by interposition of calcified tissue
Healing by interposition of fibrous tissue
Healing by bone interposition
Non-healing due to interposition of granulation tissue.
Depending on the displacement, the coronary fragment can remain alive, revascularize or necrotize:
Low-intensity trauma does not cause any displacement, therefore little or no mobility. The vitality of the pulp tissue persists, the odontoblasts initiate repair with the cement cells, thus leading to the apposition of hard tissue.
Medium-intensity trauma causes slight mobility, pulp damage generally allows revascularization. The cells that dominate the repair are those of the periodontal ligament creating an interposition of fibrous connective tissue between the fragments.
Severe trauma results in significant mobility followed by pulp necrosis and lack of healing at the fracture line with interposition of granulation tissue.
Healing
Healing by interposition of hard tissue
This type of healing is frequently found in immature teeth and when the associated periodontal trauma is not very severe. The healing callus is then formed of tertiary dentine inside the pulp cavity and osteodentine and cementum on the root surface. The two fragments are welded together and form a single entity.
Alveolo-dental trauma
Healing by interposition of connective tissue or bone tissue:
Repair is observed by interposition of a new desmodontal space between the two fragments. The dentinal surfaces facing the fracture line can be covered with cementum.
Bone interposition occurs when the space between the two fragments is wider, the fragments are then surrounded by cementum and a new periodontal ligament. The radiograph reveals a bony bridge separating the fragments while a normal periodontal ligament surrounds them.
Alveolo-dental trauma
3-5-2: Complications
Interposition of granulation tissue
In this situation, the pulp tissue of the coronal fragment is necrotic while that of the apical fragment remains vital. Pulp necrosis prevents the coalescence of the two fragments. Granulation tissue fills the fracture line and the periodontal ligament. A fistula may exist at the fracture line.
The X-ray shows an increase in the width of the fracture line and bone thinning on either side of the fracture line.
Pulp necrosis
It occurs when the aggression is severe, pulp necrosis can affect only the coronal fragment or both fragments. Endodontic treatment will only be undertaken if both fragments are realigned. If obturation of the apical fragment is impossible, only the coronal fragment is obturated and the apical fragment is surgically extracted.
Root canal obliteration
It occurs in almost all cases, there is frequently a canal obliteration of the coronal fragment and a normal pulp in the apical fragment. No treatment is necessary, only monitoring is carried out. The tooth has a more yellow color. On X-ray the obliteration can be objectified 9 to 12 months after the trauma.
Alveolo-dental trauma
4-1: Concussion and subluxation
Concussion is the shaking of the dental organ following a shock. This trauma is often caused by a frontal impact. The damage created to the periodontal ligament and pulp tissue is benign.
Subluxation is caused by a stronger shock; some desmodontal fibers can then be broken, there is edema and bleeding in the periodontal ligament
1: Diagnosis of concussion
On clinical examination, the tooth shows no mobility and no abnormal displacement compared to the contralateral teeth. Bleeding and slight edema may exist in the periodontium, the percussion test may cause slight sensitivity and chewing may be slightly painful.
No abnormalities were noted on X-ray examination.
Treatment
Consists of abstention or adjustment of the occlusion if it is traumatic. The patient is recommended to take a soft diet for 2 weeks.
Follow up
Pulp vitality is monitored for 1 to 2 months.
Prognosis
It is generally good
Alveolo-dental trauma
2- Diagnosis of subluxation
On clinical examination, abnormal mobility is observed in the vestibulolingual direction due to the rupture of certain periodontal fibers. Bleeding is visible at the gingival sulcus, the percussion test emits a dull sound and can be painful. The patient complains of having a “longer” tooth as well as discomfort when chewing. Pulp vitality tests are positive.
The X-ray examination shows no specificity.
Treatment
It consists of adjusting the occlusion if it is traumatic, prescribing a soft diet for 8 days. Contention is not always necessary, except for the patient’s comfort, it should not exceed 2 weeks.
Prognosis: It is generally good
Alveolo-dental trauma
4-2: Extrusion
An oblique shock displaces the tooth partially out of its socket. The apex is generally forced towards the vestibular alveolar wall , without fracture of this wall. Only a few palatal desmodontal fibers retain the tooth and prevent total avulsion. The periodontal ligament and the pulp are severely affected.
1: Diagnosis
On clinical examination, the crown is intact but displaced out of its socket, most often in a lingual position, the tooth appears longer than the contralateral ones. It presents great mobility.
Careful X-ray examination gives the actual degree of displacement.
The essential factor in the healing of an extrusion depends on the optimal and atraumatic repositioning of the tooth . By means of gentle digital pressure applied to the free edge of the tooth, the tooth is repositioned in its socket. In this way, the clot that has formed at the apex can be evacuated by sliding gently along the root. The retention maintains the tooth in its physiological position, thus promoting the repair process (2 to 3 weeks).
Monitoring and prognosis
Monitoring of pulp vitality is necessary 3 weeks, 2 months, 6 months and then every 6 months for 4 years.
The prognosis depends on the repositioning and the stage of root development.
4-3: Lateral dislocations
These are traumas that cause significant damage to the periodontal ligament, pulp and alveolar bone.
1: Diagnosis
The tooth appears laterally displaced and firmly locked in its new position. The crown is often forced into a lingual or palatal position and the occlusion is disturbed; there is often a clinically evident alveolar fracture. The tooth is immobile as if locked in its socket. Percussion test produces a metallic and sometimes painful sound.
On radiographic examination, the desmodontal space is thickened in the apical region, and a fracture of the vestibular bone lamina is noted.
Alveolo-dental trauma
Treatment
It consists above all of repositioning the tooth in its initial alveolar position and containing it for the time necessary for healing.
Repositioning can be done using 3 techniques:
Digital repositioning: This is the gentlest method, the practitioner stands behind the patient , with the index finger of one hand he can palpate and feel the apex of the dislocated tooth. He leans with the index finger of the other hand on the palatal surface and with firm pressure, frees the tooth from its bony blockage; a clicking sound most often occurs.
Repositioning using a forceps: In this case the root is released from its bony blockage by slight extrusion and repositioned back in its initial position.
Orthodontic repositioning: Recommended when the patient consults late.
Monitoring and prognosis
The patient should be checked every month for 5 years.
This pathology is often accompanied by pulp necrosis and inflammatory resorptions.
4-4: Intrusion
This is the most severe form of dental displacement. The shock, most often axial, forces the tooth into its socket, generally leading to its perforation. The neurovascular system of the tooth suffers considerable damage which causes pulp necrosis generating inflammatory resorptions. The desmodontal fibers are crushed.
1: Diagnosis
Clinical examination reveals a difference in height between the free edge of the traumatized tooth and the contralateral one, the tooth seems blocked in its socket. The percussion test is painful, the pulp sensitivity tests are negative.
Radiographic examination shows a decrease in the thickness of the periodontal ligament and a total disappearance at the apical region. The root is generally intact.
Alveolo-dental trauma
Treatment
It essentially depends on the stage of root development .
Immature teeth Spontaneous re-eruption is usually observed, which may take several weeks. Pulp vitality should be checked at 3 weeks, 6 weeks, every 2 months up to 5 years. If the tooth does not re-erupt spontaneously, the tooth is extruded orthodontically.
Mature teeth If the displacement is minimal, natural re-eruption can occur, pulp vitality is monitored and in case of necrosis, root canal treatment is performed. If the displacement is significant, repositioning of the tooth can be done by surgical or orthodontic means
Monitoring and prognosis
Teeth are checked at 3 weeks, 6 weeks, 2 months, 6 months and then every 6 months for 5 years. Some teeth may show ankylosis 5 years later.
The prognosis depends on the condition of the pulp and the stage of root development.
4-5: Expulsion
This is a very common accident in immature permanent teeth due to their very short roots and ligament laxity.
Repair of such trauma depends on pulp survival and healing of the periodontal ligament. The most determining factor is the extra-alveolar time.
The prognosis of treatment depends closely on the extra-alveolar time and the conservation environment:
– After 1 hour of dry storage, no periodontal cells can survive
– the pulp systematically becomes necrotic due to the rupture of the vascular-nervous bundle.
Alveolo-dental trauma
Under optimal conditions, the repair is carried out according to the following scheme:
– At the level of the periodontal ligament: After one week, we observe a revascularization of the periodontal ligament, a reattachment of the desmodontal fibers on the root and the formation of a new gingival attachment.
– At the pulp level: Revascularization begins 4 days after the trauma and progresses ½ mm per mm/day. Sensitivity tests may be positive only 2 months after the trauma
1: Diagnosis
The clinical examination corresponds to the complete displacement out of its socket. The socket is uninhabited. If the tooth is found, the entire root must be checked.
Radiographic examination may reveal the existence or absence of an associated alveolar fracture.
Treatment
4-5-2-1: Purposes of processing
This trauma requires emergency treatment , the desmodontal cells dry out and die within 30 minutes. There are two treatment options: Immediate reimplantation, delayed reimplantation.
4-5-2-2: Emergency treatment
1st session
Reimplantation at the accident site is recommended. The practitioner may advise the patient to reimplant his tooth at the site. If this is not possible or is refused. He recommends immersing it in a suitable environment (milk or physiological serum).
Once the patient is in the office, the tooth is examined and cleaned with physiological serum. The socket is gently rinsed with physiological serum to eliminate the clot causing ankylosis.
If the extra-alveolar time is less than 60 minutes, and the apex is mature, the tooth is gently replaced in the alveolus with light digital pressure. The radiograph checks for correct repositioning.
If the extra-alveolar time is greater than 60 min and the apex is immature, periodontal repair and pulp revascularization are possible, reimplantation is carried out as for the mature tooth.
A restraint is placed for 2 weeks.
The necessary prescriptions are (oral hygiene, chlorhexidine mouthwash/10 days, ATB and painkiller coverage/4 days.
2nd session
One week later, the root canal treatment is carried out with intermediate root canal filling with calcium hydroxide. The definitive root canal filling is carried out 1 year later.
Alveolo-dental trauma
Follow up
Check-ups are done every 3 weeks, 6 weeks and then every year for 5 years.
Prognosis
It mainly depends on 3 factors:
Extra-alveolar time
The conservation environment
The stage of root development.